GROWTH HORMONE THERAPY: Genotropin (somatropin) subcutaneous injection Humatrope (somatropin) subcutaneous injection Norditropin (somatropin) subcutaneous injection Nutropin AQ (somatropin) subcutaneous injection Omnitrope (somatropin) subcutaneous injection Saizen (somatropin) subcutaneous injection Serostim (somatropin) subcutaneous injection Zomacton (somatropin) subcutaneous injection Zorbtive (somatropin) subcutaneous injection Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Pharmacy Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Pharmacy Coverage Guidelines are subject to change as new information becomes available. For purposes of this Pharmacy Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other trademarks and service marks contained in this guideline are the property of their respective owners, which are not affiliated with BCBSAZ. This Pharmacy Coverage Guideline does not apply to FEP or other states Blues Plans. Information about medications that require precertification is available at www.azblue.com/pharmacy. Some large (100+) benefit plan groups may customize certain benefits, including adding or deleting precertification requirements. Page 1 of 20
All applicable benefit plan provisions apply, e.g., waiting periods, limitations, exclusions, waivers and benefit maximums. Precertification for medication(s) or product(s) indicated in this guideline requires completion of the request form in its entirety with the chart notes as documentation. All requested data must be provided. Once completed the form must be signed by the prescribing provider and faxed back to BCBSAZ Pharmacy Management at (602) 864-3126 or emailed to Pharmacyprecert@azblue.com. Incomplete forms or forms without the chart notes will be returned. Section A. Applies for all indications and uses: Criteria for initial therapy: Somatropin injection is considered medically necessary and will be approved when ALL of the following criteria are met: 1. Prescriber is a physician specializing in or is in consultation with an Endocrinologist, Nephrologist, Infectious Disease, or Trauma/Burn Surgery depending upon indication or use 2. Meets other initial criteria per indication or use as described below in Sections B-F below 3. Individual has failure, contraindication or intolerance to the preferred growth hormone therapy medication Nutropin AQ OR the preferred growth hormone therapy medication is not indicated for the condition 4. Somatropin agents or Increlex (mecasermin) will not be used in combination 5. There are NO contraindications (See Definitions section) 6. Meets other initial criteria as described below in Sections B-G below See section B for Growth Hormone Deficiency under 18 years of age See section C for Growth Hormone Deficiency 18 years of age and older See section D for Burns See section E for HIV/AIDS Wasting Syndrome See section F for Short Bowel Syndrome See section G for Small for Gestational Age See section H for Idiopathic Short Stature See section I for Other uses Criteria for continuation of coverage (renewal request): Somatropin injection is considered medically necessary and will be approved when ALL of the following criteria are met: 1. Individual continues to be seen by a physician specializing in or is in consultation with an Endocrinologist, Nephrologist, Infectious Disease, or Trauma/Burn Surgery depending upon indication or use 2. Meets other continuation criteria per indication or use as described in Sections B-F below 3. Somatropin agents will not be used in combination or in combination with Increlex (mecasermin) Page 2 of 20
4. Individual has been adherent with the medication 5. Individual has not developed any contraindications or other significant level 4 adverse drug effects that may exclude continued use 6. There are no significant interacting drugs 7. Meets other initial criteria as described below in Sections B-I below See section B for Growth Hormone Deficiency under 18 years of age See section C for Growth Hormone Deficiency 18 years of age and older See section D for Burns See section E for HIV/AIDS Wasting Syndrome See section F for Short Bowel Syndrome See section G for Small for Gestational Age See section H for Idiopathic Short Stature See section I for Other uses Section B. Growth Hormone Deficiency for Individuals Under 18 Years of Age: Criteria for initial therapy: Initial course of treatment of Somatropin injection therapy for individuals under 18 years of age may be considered medically necessary with documentation of ALL of the following: 1. Meets other initial criteria as described in Section A above 2. A confirmed diagnosis of ONE of the following: Individual with proven growth failure due to growth hormone deficiency (GHD) as documented by ALL of the following: One growth hormone stimulation test with a peak value < 10 ng/ml Bone age is less than the individual s chronological age and the individual s chronological age is prior to gender-appropriate age for bone maturation (14 years for females, 16 years for males) IGF-1 is subnormal result for age as indicated by the table in the Description Section IGFBP-3 is subnormal result for age as indicated by the table in the Description Section Individual with growth failure/short stature due to chronic renal insufficiency (defined as a serum creatinine > 1.4 mg/dl (women) or > 1.7 mg/dl (men) or a creatinine clearance of < 75 ml/min/1.73 m 2 ) pending transplantation Individual with growth failure/short stature due to Noonan s Syndrome Individual with growth failure/short stature due to Prader-Willi Syndrome in the absence of upper airway obstruction or sleep apnea or severe respiratory impairment by sleep study Individuals with growth failure/short stature due to short stature homeobox-containing gene (SHOX) deficiency Page 3 of 20
Individual with growth failure/short stature due to Turner s Syndrome defined as 45, XO genotype 3. Documentation that height is at least two standard deviations below the mean for individual s chronologic age and gender 4. Individual has recent (within the last 12 months) radiographic evidence of open epiphyses Initial approval duration: If approved, may be authorized for a maximum of 12 months Criteria for continuation of coverage (renewal request): Continuing or repeat courses of treatment of Somatropin injection therapy for individuals under 18 years of age are considered medically necessary with documentation that the individual has been compliant with treatment and documentation of ANY of the following: 1. Meets other continuation criteria as described in Section A above 2. Individual s condition responded while on therapy Response is defined as: For proven GHD, Noonan syndrome, Prader-Willi syndrome, SHOX deficiency, or Turner s syndrome: Height has increased at least 2-5 cm/year over the previous year (previous height and date obtained and current height and date obtained must be sent) Has not obtained expected adult height (expected height goal must be sent) For short stature in CRI Individual is pending transplantation (Note: will not be approved if transplantation has occurred) Height has increased at least 2-5 cm/year over the previous year (previous height and date obtained and current height and date obtained must be sent) Has not obtained expected adult height (expected height goal must be sent) 3. Recent (within the last 12 months) radiographic evidence of open epiphyses Renewal duration: If approved, may be authorized for a maximum of 12 months per request Section C. Growth Hormone Deficiency for Individuals 18 Years of Age and Older: Criteria for initial therapy: Initial course of treatment Somatropin injection therapy for individuals 18 years of age and older may be considered medically necessary with documentation of ALL of the following: 1. Meets other initial criteria as described in Section A above Page 4 of 20
2. A confirmed diagnosis of ONE of the following: Individual with proven childhood-onset GHD (acquired or idiopathic or received growth hormone in childhood) and whose epiphyses have closed with documentation of ALL of the following: Individual has been retested to determine if on-going replacement therapy is needed The results of TWO abnormal provocative stimulation tests demonstrate growth hormone peak value < 5 ng/ml by RIA or peak value < 2.5 ng/ml by IRMA (Note: time of administration of the provocative agent & the number of minutes elapsed between provocative agent administration time and drawing of serum GH level must be sent) Individual with suspected adult-onset GHD with documentation of the following: The results of TWO abnormal provocative stimulation tests demonstrate growth hormone peak value < 5 ng/ml by RIA or peak value < 2.5 ng/ml by IRMA (Note: time of administration of the provocative agent & the number of minutes elapsed between provocative agent administration time and drawing of serum GH level must be sent) Individual with surgery, irradiation or trauma involving the hypothalamus or pituitary gland, or other diseases of the hypothalamus or pituitary gland with documentation of ALL of the following: The results of ONE abnormal provocative stimulation test demonstrate growth hormone peak value < 5 ng/ml by RIA or peak value < 2.5 ng/ml by IRMA (Note: time of administration of the provocative agent & the number of minutes elapsed between provocative agent administration time and drawing of serum GH level must be sent) Individual with multiple pituitary hormone deficiencies other than growth hormone (i.e., TSH, ACTH, LH and/or FSH, AVP) and serum insulin-like growth factor 1 (IGF-1) less than the lower limit of normal for the assay that was used Individual with congenital/genetic growth hormone deficiency such as Noonan syndrome, Prader-Willi Syndrome, short stature homeobox-containing gene (SHOX) deficiency, or Turner s syndrome Initial approval duration: If approved, may be authorized for a maximum of 12 months. Criteria for continuation of coverage (renewal request): Continuing or repeat courses of treatment of Somatropin injection therapy for individuals 18 years of age and older are considered medically necessary with documentation that the individual has been compliant with treatment and documentation of ANY of the following: 1. Meets other continuation as described in Section A above 2. Individual s condition responded while on therapy Individual with proven childhood-onset GHD (acquired or idiopathic or received growth hormone in childhood) or suspected adult-onset GHD Historical clinical records of two abnormal provocative stimulation tests Page 5 of 20
Individual with surgery, irradiation or trauma involving the hypothalamus or pituitary gland or other diseases of the pituitary or hypothalamus Historical clinical records of one abnormal provocative stimulation test Clinical records document that without ongoing treatment with growth hormone (GH), signs or symptoms of GH deficiency would reappear, or if a gap in treatment occurred, low GH levels or signs and symptoms of GH deficiency reappeared 3. Individual with multiple pituitary hormone deficiencies other than growth hormone (i.e., TSH, ACTH, LH and/or FSH, AVP) and serum insulin-like growth factor 1 (IGF-1) less than the lower limit of normal for the assay that was used 4. Individual with congenital/genetic growth hormone deficiency such as Noonan syndrome, Prader-Willi Syndrome, short stature homeobox-containing gene (SHOX) deficiency, or Turner s syndrome Renewal duration: If approved, may be authorized for a maximum of 12 months per request Section D. Burns: Criteria for initial therapy: Somatropin injection therapy is considered medically necessary for the treatment of severe burns with documentation of ALL the following: 1. Meets other initial criteria per indication or use as described in Section A above 2. A confirmed diagnosis of ONE of the following: Individual with extensive 3 rd degree burns showing difficulty with wound healing Children with severe burns that cover at least 40% of total body surface area, to prevent growth delay Approval duration: For up to 1 year after the burn Section E. HIV/AIDS Wasting: (Serostim only) Criteria for initial therapy: Serostim for the treatment of HIV/AIDS wasting syndrome or cachexia is considered medically necessary with documentation of ALL of the following: 1. Meets other initial criteria as described in Section A above 2. Individual is 18 years of age or older 3. There is ONE of the following: Unintentional/involuntary weight loss of at least 10% of ideal (standard) body weight for height and weight (see women s/men s weight at different ages charts in Definitions Section) within the last 12 months Page 6 of 20
Unintentional/involuntary weight loss to a BMI of < 20 kg/m 2 4. Weight loss is not explained by another concurrent illness other than HIV/AIDS infection 5. There is continued weight loss despite adequate nutrition and other measures 6. Individual is currently receiving optimal antiretroviral drug therapy for HIV/AIDS positive disorder to decrease the viral load 7. Will not be used as intermittent therapy for maintenance 8. Individual has failure, contraindication or intolerance to megestrol or dronabinol Initial approval duration: 12 weeks Criteria for continuation of coverage (renewal request): Serostim for the treatment of HIV/AIDS wasting syndrome or cachexia is considered medically necessary with documentation of ALL of the following: 1. Meets other continuation criteria as described in Section A above 2. Individual s condition responded while on therapy Response is defined as: Weight loss has improved or weight has stabilized during the initial 12 weeks but target body mass index or weight has not been achieved 3. Individual is currently receiving optimal antiretroviral drug therapy for HIV/AIDS positive disorder to decrease the viral load 4. Will not be used as intermittent therapy for maintenance Renewal duration: Total course: 48 weeks (includes the duration of use under Initial approval) Section F. Short Bowel Syndrome: (Zorbtive only) Criteria for therapy: Zorbtive for the treatment of short bowel syndrome is considered medically necessary with documentation of ALL of the following: 1. Meets other initial criteria as described in Section A above 2. Individual is 18 years of age or older 3. Documentation that at least 50% of the small intestine has been removed Page 7 of 20
4. Individual is on concurrent specialized nutritional support (i.e., high-carbohydrate, low-fat diet adjusted for individual patient requirements, such as dietary adjustments, enteral feedings, parenteral nutrition, fluid and micronutrient supplements) 5. There is NO history of previous use of Zorbtive for 4 weeks for short bowel syndrome Approval duration: Single 4-week course only Section G. Small for Gestationa Age (SGA): COVERAGE FOR TREATMENT TO CORRECT A CONGENITAL DEFECT OR BIRTH ABNORMALITY IS DEPENDENT UPON BENEFIT PLAN LANGUAGE AND IS SUBJECT TO THE PROVISIONS OF THE RECONSTRUCTIVE BENEFIT AND THE COSMETIC BENEFIT EXCLUSION. REFER TO MEMBER S SPECIFIC BENEFIT PLAN BOOKLET TO VERIFY BENEFITS AND THE FUNCTIONAL IMPAIRMENT REQUIREMENT. Somatropin injection therapy for the treatment of children born small for gestational age (SGA), including those who have failed to manifest catch-up growth by two years of age, is considered not medically necessary and not eligible for coverage due to lack of an associated functional impairment. Section H. Idiopathic Short Stature (ISS): Somatropin injection therapy for treatment of idiopathic short stature, without documentation of growth hormone deficiency, is a benefit plan exclusion and not eligible for coverage. Section I. Other Uses: Somatropin injection therapy for all other indications not previously listed is considered experimental or investigational based upon: 1. Lack of final approval from the Food and Drug Administration, and 2. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 3. Insufficient evidence to support improvement of the net health outcome, and 4. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives, and 5. Insufficient evidence to support improvement outside the investigational setting. These indications include, but are not limited to: Improvement of neurodevelopmental status (intelligence) Prevention of dyslipidemia, insulin resistance and/or metabolic syndrome (diabetes, hypertension, obesity) Altered body habitus, e.g., buffalo hump, associated with antiviral therapy in individuals with HIV Anabolic therapy to counteract acute or chronic illness (surgery outcomes, trauma, cancer, chronic hemodialysis, chronic infectious disease) that produces catabolic (protein wasting) changes in both adults and children, except as specified for AIDS and short bowel syndrome Page 8 of 20
Anabolic therapy to counteract the gradual declines in muscle and bone mass that occur with aging Anabolic therapy to enhance body mass and strength for professional, recreational or social reasons Constitutional delay Cystic fibrosis Growth failure as the result of glucocorticoids Idiopathic dilated cardiomyopathy Intrauterine growth retardation Juvenile idiopathic or juvenile chronic arthritis Obesity Precocious puberty in conjunction with gonadotropin releasing hormone (GnRH) analogs Short stature after renal transplantation Short stature as the result of Down Syndrome Treatment of children with genetic potential (i.e., lower than expected height percentiles based on parents height) Treatment with dosing or frequency outside the FDA-approved dosing and frequency Description: Somatropin is a synthetically produced growth hormone (GH). Somatropin is indicated for the treatment of growth hormone deficiency (GHD), short stature associated with Turner syndrome (TS) or Noonan syndrome (NS), shortstature homeobox (SHOX) gene deficiency, growth failure due to Prader-Willi syndrome (PWS), short stature in children born small for gestational age (SGA), growth failure in children with chronic renal insufficiency (CRI) or chronic kidney disease (CKD) up to the time of transplant, idiopathic short stature (ISS), to promote wound healing in burns, short bowel syndrome (SBS) in patients receiving specialized nutritional support, and HIVassociated wasting. Somatropin is also indicated for replacement of endogenous growth hormone in adults with confirmed GHD. Short stature, such as in idiopathic short stature (ISS) and in small for gestational age (SGA), in the absence of defined pathology is not a sickness or injury; growth hormone is not a covered health service for these indications. Growth Hormone Deficiency (GHD) is defined as the inadequate secretion of endogenous growth hormone. GHD may be idiopathic or organic and can occur in childhood or adulthood. Pathophysiology differs between the two onsets. GHD is diagnosed through a combination of clinical and biochemical examination, testing and analysis. Children with GHD generally present with short stature and growth velocity that is two (2) standard deviations below the mean for chronologic age, sex and pubertal stage. Often the etiology is isolated idiopathic GHD. GHD in adults often results from conditions affecting the hypothalamus or pituitary gland including surgery and radiation therapy. Adults frequently report symptoms such as unintentional weight gain or difficulty losing weight, low energy, reduced physical performance, decreased libido, impaired psychological well-being and a feeling that things are not right. Physical findings may include increased fat mass, decreased lean body and muscle mass, decreased bone density as well as reduced muscle strength and exercise capacity. There is however no single symptom or sign that is pathognomonic for GHD in adults. In addition, some adults with GHD may be entirely asymptomatic. Page 9 of 20
Growth Hormone (GH) provocative stimulation test is one of the procedures that may be performed to diagnose growth hormone deficiency (GHD). A provocative agent is used to stimulate the pituitary gland to secrete GH. The intent is to determine the maximum peak GH response from the provocative agent. The peak is the value used to determine whether the response is considered normal or abnormal for the purpose of supporting the diagnosis of GHD. Serum levels may be measured by radioimmunoassay (RIA) or immunoradiometric assay (IRMA). GH secretion is pulsatile. There are approximately 10 pulses of GH secretion per day, lasting approximately 90 minutes and separated by roughly 128 minutes. Nearly 50% of samples collected during the day in normal subjects have undetectable serum GH concentrations. In addition, GH is undetectable in over 95% of samples in obese or older subjects. Baseline testing is performed prior to administration of the provocative agent and frequent blood sampling is done thereafter. Sampling occurs approximately 30, 60, 90, 120 and 180 minutes after provocative agent administration. Sampling defines the curve of the response (going from a lower GH value prior to provocation to the highest, or peak, GH value after provocation and then a drop from peak) and must provide sufficient information to determine a peak value. Definitions: Adult: Age 18 years and older Somatropin products: Genotropin Humatrope Norditropin Nutropin AQ preferred product Omnitrope Saizen Serostim Zomacton Zorbtive Contraindications to use of somatropin include: Active malignancy Active proliferative or severe non-proliferative diabetic retinopathy Acute critical illness in response to open heart surgery, abdominal surgery, multiple accidental trauma, or acute respiratory failure Growth promotion in pediatric individuals with closed epiphysis Pediatric individuals with Prader-Willi syndrome who are severely obese or have history of upper airway obstruction or sleep apnea or have severe respiratory impairment by sleep study Known hypersensitivity to the drug or any diluent (benzyl alcohol, m-cresol) or any other ingredient of the formulation Page 10 of 20
Growth Hormone (GH) Provocative Stimulation Tests: Arginine HCL Test Arginine/L-Dopa Test Clonidine Test Glucagon Stimulation Test Growth Hormone Releasing Hormone Test (GHRH) Insulin Tolerance Test (ITT) or Insulin Induced Hypoglycemic Test L-Dopa Test Propranolol/Glucagons Test Physiological: sleep-induced or exercise-induced stimulation Macimorelin: a ghrelin agonist Insulin-Like Growth Factor 1 (IGF-1): A hormone created mainly by the liver that mediates most of the effects of growth hormone. IGF-1 blood tests may be used in the diagnosis of growth hormone deficiency. AGE SUBNORMAL RESULT 7 years 1 Less than 52 ng/ml 8 through 10 years Less than 75 ng/ml 11 through 12 years Less than 127 ng/ml 13 through 17 years Less than 212 ng/ml 1 Limited safety and efficacy data are available below the age of 7. Insulin-Like Growth Factor Binding Protein (IGFBP-3): The transport protein for IGF-1 and IGF-2 in the circulation. It modulates IGF activity and inhibits cell growth. Its levels increase in the presence of IGF-I, insulin and other growth-stimulating factors such as growth hormone. IGFBP-3 blood tests may be used in the diagnosis of growth hormone deficiency. AGE SUBNORMAL RESULT AGE SUBNORMAL RESULT 7 years 1 Less than 1.4 mg/l 13 years Less than 3.1 mg/l 8 years Less than 1.6 mg/l 14 years Less than 3.1 mg/l 9 years Less than 1.8 mg/l 15 years Less than 3.5 mg/l 10 years Less than 2.1 mg/l 16 years Less than 3.4 mg/l 11 years Less than 2.4 mg/l 17 years Less than 3.2 mg/l 12 years Less than 2.7 mg/l 1 Limited safety and efficacy data are available below the age of 7. Functional Impairment: A state in which the normal or proper action (function) of any body part or organ is damaged or deficient as a result of growth hormone deficiency. Page 11 of 20
Burn evaluation: Extent of total body surface area expressed as a percent Rule of 9s for adult: o Head 9% o Each arm 9% o Anterior chest and abdomen 18% o Posterior chest and back 18% o Each leg 18% o Perineum 1% Rule of 9s for child: o Head 18% o Each leg 13.5% o Then the rest as above Depth of burn, estimates the depth of burn affecting the outer epidermis and dermis: First degree: superficial, only involves the epidermis Second degree: partial thickness, extends through the epidermis and into the dermis Third degree: full thickness, extends through the epidermis, into the dermis and into the subcutaneous fat Fourth degree: damage the underlying bones, muscles, and tendons Short Bowel Syndrome: A malabsorption syndrome resulting from surgical removal of at least 50% of the small intestine. According to the American Gastroenterological Association, SBS is a disorder that is defined clinically as malabsorption, diarrhea, fluid and electrolyte disturbances, and malnutrition. In SBS there is functional or anatomical loss of extensive segments of the small intestines, with resultant compromised absorptive capacity. Idiopathic Short Stature (ISS): ISS (also known as non-growth hormone-deficient short stature) is extreme short stature that does not have a diagnostic explanation after a growth evaluation documenting normal physical function and normal lab tests. ISS includes short stature without documentation of growth hormone deficiency and children are identified as being abnormally short. ISS may also be referred to as short stature of undefined cause. Small for gestational age (SGA): A term used to describe a baby who is smaller than the usual amount for the number of weeks of pregnancy. SGA is most commonly defined as a weight below the 10th percentile for the gestational age. Abnormally Short: Boys: Height predicted to be shorter than 5 feet 3 inches Girls: Height predicted to be shorter than 4 feet 11 inches Page 12 of 20
Body weight for height charts for woman and men: WEIGHT FOR WOMEN AT DIFFERENT AGES Age 18 to 29 Age 30 to 44 Age 45 to 65 Height 25% 40% 25% 40% 25% 40% UW SW OW UW SW OW UW SW OW 4'11" 85 113 158 89 119 167 95 126 176 5'0" 86 114 160 92 122 171 97 129 181 5'1" 87 116 162 93 124 174 99 132 185 5'2" 89 118 165 95 127 178 101 135 189 5'3" 92 122 171 98 131 183 104 139 195 5'4" 94 125 175 101 134 188 107 143 200 5'5" 96 128 179 104 139 195 111 148 207 5'6" 99 132 185 107 143 200 114 152 213 5'7" 101 135 189 110 147 206 116 155 217 5'8" 105 140 196 113 151 211 119 159 223 5'9" 108 144 202 116 155 217 123 164 230 5'10" 110 147 206 119 159 223 126 168 235 5'11" 112 149 209 122 163 228 129 172 241 6'0" 113 151 211 125 167 234 132 176 246 6'1" 115 153 214 127 169 237 135 180 252 6'2" 116 155 217 128 171 239 138 184 258 Legend: UW: underweight SW: standard weight OW: over weight Page 13 of 20
WEIGHT FOR MEN AT DIFFERENT AGES Age 18 to 29 Age 30 to 44 Age 45 to 65 Height 25% 40% 25% 40% 25% 40% UW SW OW UW SW OW UW SW OW 5'0" 94 125 175 98 131 183 101 134 188 5'1" 95 126 176 99 132 185 102 136 190 5'2" 96 128 179 100 133 186 104 138 193 5'3" 98 131 183 102 136 190 106 141 197 5'4" 101 135 189 105 140 196 109 145 203 5'5" 104 138 193 107 143 200 112 149 209 5'6" 107 142 199 110 147 206 115 153 214 5'7" 110 147 206 114 152 213 119 158 221 5'8" 113 151 211 118 157 220 122 163 228 5'9" 116 155 217 122 162 227 126 168 235 5'10" 119 159 223 125 167 234 130 173 242 5'11" 123 164 230 130 173 242 134 178 249 6'0" 128 170 238 134 179 251 137 183 256 6'1" 133 177 248 139 185 259 142 189 264 6'2" 138 184 258 145 193 270 146 194 272 6'3" 143 190 266 149 198 277 150 200 280 6'4" 147 196 274 152 203 284 155 206 288 6'5" 151 201 281 155 207 290 158 211 295 6'6" 155 206 288 158 211 295 162 216 302 6'7" 157 209 293 161 215 301 166 221 309 6'8" 161 214 300 164 219 307 170 226 316 Legend: UW: underweight SW: standard weight OW: over weight Page 14 of 20
Summary of FDA-approved Indications: Somatropin: Summary of FDA Indications Genotropin Humatrope Norditropin Nutropin AQ Omnitrope Saizen Serostim Zomacton Zorbtive Condition Adult GHD a Pediatric GHD b Growth failure with CKD c Idiopathic short stature (ISS) d Noonan syndrome (NS) Prader-Willi syndrome (PWS) Short bowel syndrome (SBS) SHOX deficiency e Turner syndrome (TS) Small for gestational age (SGA) g h h g Wasting or cachexia in adults with HIV f a Adult Growth hormone deficiency (GHD) may be either: (1) adult-onset (patients who have GHD, either alone or associated with multiple hormone deficiencies [hypopituitarism], as a result of pituitary disease, hypothalamic disease, surgery, radiation, or trauma) or (2) childhoodonset (patients who were GHD during childhood as a result of congenital, genetic, acquired, or idiopathic causes). Patients who were treated with somatropin for GHD in childhood and whose epiphyses are closed should be reevaluated before continuation of somatropin therapy at the reduced dose level recommended for GHD adults. According to current standards, confirmation of the diagnosis of adult growth hormone deficiency in both of the above groups involves an appropriate growth hormone provocative test with two exceptions: (1) patients with multiple other pituitary hormone deficiencies due to organic disease; and (2) patients with congenital/genetic growth hormone deficiency b Caused by an inadequate secretion of endogenous growth hormone c CKD = chronic kidney disease. Use up until the time of renal transplantation and in conjunction with optimal management of CKD. d Also called non-growth hormone-deficient short stature (defined by height standard deviation score [SDS] less than or equal to 2.25) and associated with growth rates unlikely to permit attainment of adult height in the normal range in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means. e SHOX = short stature homeobox-containing gene f Concomitant antiretroviral therapy is necessary g For children who fail to manifest catch-up growth by 2 years of age h For children with no catch-up growth by 2 to 4 years of age Brand Tev-Tropin was renamed to Zomacton Resources: 1. 5.01.06 Blue Cross Blue Shield Association Medical Policy Reference Manual. Human Growth Hormone. Re-issue date 10/12/2017, issue date 11/01/1997. 2. American Association of Clinical Endocrinologists. Medical Guidelines for Clinical Practice for Growth Hormone Use in Adults and Children 2003 Update. 01/2003. Page 15 of 20
3. BCBS Association Technology Assessment Program. Recombinant Human growth Hormone (GH) Therapy in Adults with Age-Related GH Deficiency. 04/2002. 4. Binder G, Seidel AK, Martin DD, et al. The endocrine phenotype in silver-russell syndrome is defined by the underlying epigenetic alteration. J Clin Endocrinol Metab. 2008 Apr 2008;93(4):1402-1407. 5. Bryant J, Baxter L, Cave CB, Milne R. Recombinant growth hormone for idiopathic short stature in children and adolescents. Cochrane Database Syst Rev. 2007 2007(3):CD004440. 6. Chatelain P, Carrascosa A, Bona G, Ferrandez-Longas A, Sippell W. Growth hormone therapy for short children born small for gestational age. Horm Res. 2007 2007;68(6):300-309. 7. Crabbe R, von Holtey M, Engrand P, Chatelain P. Recombinant human growth hormone for children born small for gestational age: meta-analysis confirms the consistent dose-effect relationship on catch-up growth. J Endocrinol Invest. 2008 Apr 2008;31(4):346-351. 8. De Schepper J, Thomas M, Beckers D, Craen M, Maes M, de Zegher F. Growth hormone treatment and fat redistribution in children born small for gestational age. J Pediatr. 2008 Mar 2008;152(3):327-330. 9. Delemarre EM, Rotteveel J, Delemarre-van de Waal HA. Metabolic implications of GH treatment in small for gestational age. Eur J Endocrinol. 2007 Aug 2007;157 Suppl 1:S47-50. 10. Edouard T, Oliver I, Jouret B, et al. [Growth follow-up of SGA children after 3 years of GH treatment]. Arch Pediatr. 2008 Feb 2008;15(2):115-121. 11. Eledrisi, M. Growth Hormone Deficiency. emedicine Specialties. Updated 05/12/2006. 12. External Consultant Review. Pediatric Endocrinology & Diabetes. 06/01/2009. 13. External Consultant Review. Pediatric Endocrinology & Diabetes Division Chief. 08/27/2009. 14. External Consultant Review. Pediatric Endocrinology. 02/08/2009. 15. External Consultant Review. Pediatric Endocrinology and Diabetes. 02/27/2009. 16. External Consultant Review. Pediatrics. 01/06/2009. 17. External Consultant Review. Division Chief Pediatric Endocrinology & Diabetes Phoenix Children's Hospital. 07/08/2009. 18. External Consultant Review. The Pediatric Endocrine & Diabetes Clinic, PC. 06/11/09. 19. FDA. FDA Talk Paper: FDA Approves Humatrope for Short Stature. 07/25/2003. 20. FDA. Genotropin Supplement Number 044 Letter. 10/31/2003. 21. FDA. Serostim Supplement 027 Letter. 08/29/2003. Page 16 of 20
22. Lawson Wilkins Pediatric Endocrine Society, Collett-Solberg, P, Misra, M. Draft Statement Under Development-Working Document: The Role of rhigf-i in Treating Children with short Stature. Accessed 10/24/2007. 23. Poduval A, Saenger P. Safety and efficacy of growth hormone treatment in small for gestational age children. Curr Opin Endocrinol Diabetes Obes. 2008 Aug 2008;15(4):376-382. 24. Schweizer R, Martin DD, Schonau E, Ranke MB. Muscle function improves during growth hormone therapy in short children born small for gestational age: results of a peripheral quantitative computed tomography study on body composition. J Clin Endocrinol Metab. 2008 Aug 2008;93(8):2978-2983. 25. Sgambat K, Moudgil A. Optimization of Bone Health in Children before and after Renal Transplantation: Current Perspectives and Future Directions. Frontiers in pediatrics. 2014;2:13. 26. Simon D, Leger J, Carel JC. Optimal use of growth hormone therapy for maximizing adult height in children born small for gestational age. Best Pract Res Clin Endocrinol Metab. 2008 Jun 2008;22(3):525-537. 27. UpToDate.com. Growth hormone treatment for children born small for gestational age. 01/10/2014. 28. UpToDate.com. Growth hormone treatment in children with chronic kidney disease and postrenal transplantation. 11/08/2013. 29. UpToDate.com. Infants with fetal (intrauterine) growth restriction. 12/01/2015. 30. Walenkamp MJ, de Muinck Keizer-Schrama SM, de Mos M, et al. Successful long-term growth hormone therapy in a girl with haploinsufficiency of the insulin-like growth factor-i receptor due to a terminal 15q26.2->qter deletion detected by multiplex ligation probe amplification. J Clin Endocrinol Metab. 2008 Jun 2008;93(6):2421-2425. UpToDate: Physiology of growth hormone. Current through Nov 2018. https://www-uptodatecom.mwu.idm.oclc.org/contents/physiology-of-growthhormone?search=growth%20hormone&source=search_result&selectedtitle=2~150&usage_type=default&display _rank=2#h201813208 UpToDate: Diagnosis of growth hormone deficiency in children. Current through Nov 2018. https://www-uptodatecom.mwu.idm.oclc.org/contents/diagnosis-of-growth-hormone-deficiency-inchildren?search=growth%20hormone&source=search_result&selectedtitle=4~150&usage_type=default&display_ rank=4 UpToDate: Growth hormone deficiency in adults. Current through Nov 2018. https://www-uptodatecom.mwu.idm.oclc.org/contents/growth-hormone-deficiency-inadults?search=growth%20hormone&source=search_result&selectedtitle=3~150&usage_type=default&display_ra nk=3 Page 17 of 20
UpToDate: Treatment of growth hormone deficiency in children. Current through Nov 2018. https://www-uptodatecom.mwu.idm.oclc.org/contents/treatment-of-growth-hormone-deficiency-inchildren?search=growth%20hormone&source=search_result&selectedtitle=1~150&usage_type=default&display_ rank=1 UpToDate: Growth hormone treatment during the transition period. Current through Nov 2018. https://wwwuptodate-com.mwu.idm.oclc.org/contents/growth-hormone-treatment-during-the-transitionperiod?search=growth%20hormone&source=search_result&selectedtitle=7~150&usage_type=default&display_r ank=7 UpToDate: Growth hormone metabolism in chronic kidney disease. Current through Nov 2018. https://www-uptodate-com.mwu.idm.oclc.org/contents/growth-hormone-metabolism-in-chronic-kidneydisease?search=growth%20hormone&source=search_result&selectedtitle=8~150&usage_type=default&display_ rank=8 Page 18 of 20
Fax completed prior authorization request form to 602-864-3126 or email to pharmacyprecert@azblue.com. Call 866-325-1794 to check the status of a request. All requested data must be provided. Incomplete forms or forms without the chart notes will be returned. Pharmacy Coverage Guidelines are available at www.azblue.com/pharmacy. Pharmacy Prior Authorization Request Form Do not copy for future use. Forms are updated frequently. REQUIRED: Office notes, labs, and medical testing relevant to the request that show medical justification are required. Member Information Member Name (first & last): Date of Birth: Gender: BCBSAZ ID#: Address: City: State: Zip Code: Prescribing Provider Information Provider Name (first & last): Specialty: NPI#: DEA#: Office Address: City: State: Zip Code: Office Contact: Office Phone: Office Fax: Dispensing Pharmacy Information Pharmacy Name: Pharmacy Phone: Pharmacy Fax: Requested Medication Information Medication Name: Strength: Dosage Form: Directions for Use: Quantity: Refills: Duration of Therapy/Use: Check if requesting brand only Check if requesting generic Check if requesting continuation of therapy (prior authorization approved by BCBSAZ expired) Turn-Around Time For Review Standard Urgent. Sign here: Exigent (requires prescriber to include a written statement) Clinical Information 1. What is the diagnosis? Please specify below. ICD-10 Code: Diagnosis Description: 2. Yes No Was this medication started on a recent hospital discharge or emergency room visit? 3. Yes No There is absence of ALL contraindications. 4. What medication(s) has the individual tried and failed for this diagnosis? Please specify below. Important note: Samples provided by the provider are not accepted as continuation of therapy or as an adequate trial and failure. Medication Name, Strength, Frequency Dates started and stopped or Approximate Duration Describe response, reason for failure, or allergy 5. Are there any supporting labs or test results? Please specify below. Date Test Value Blue Cross Blue Shield of Arizona, Mail Stop A115, P.O. Box 13466, Phoenix, AZ 85002-3466 Page 1 of 2
Pharmacy Prior Authorization Request Form 6. Is there any additional information the prescribing provider feels is important to this review? Please specify below. For example, explain the negative impact on medical condition, safety issue, reason formulary agent is not suitable to a specific medical condition, expected adverse clinical outcome from use of formulary agent, or reason different dosage form or dose is needed. Signature affirms that information given on this form is true and accurate and reflects office notes Prescribing Provider s Signature: Date: Please note: Some medications may require completion of a drug-specific request form. Incomplete forms or forms without the chart notes will be returned. Office notes, labs, and medical testing relevant to the request that show medical justification are required. Blue Cross Blue Shield of Arizona, Mail Stop A115, P.O. Box 13466, Phoenix, AZ 85002-3466 Page 2 of 2